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Who are we?
We are a group of professionals, carers and services users who are inspired by the work of Loren Mosher et al. at Soteria House in the 1970s and 1980s, as well as similar approaches that have been developed internationally, and who would like to see such services developed in Brighton as well as nationally. You can find further information on the Soteria model and the evidence base for it below.
We are troubled by the lack of choice in services for people experiencing ‘psychosis’. Typically this is limited to a period of inpatient treatment, and the long-term use of antipsychotic medication. Patient choice sits at the center of current UK governmental health reforms (1,2) and has been cited as a vital component of an evidence-based and patient-centred mental health care system (3-5). However, patient choice is generally limited to having some say over which antipsychotic is prescribed. Given that the vast majority of service users and providers support the idea of residential crisis services as an alternative to acute inpatient treatment (6), clearly there is an urgent need to develop such alternatives.
Soteria Brighton is not anti-hospital, not anti-medication, and not anti-psychiatry. We realise that for some the containment offered by a period of time in hospital may be necessary. However, we believe that, because of the lack of choice, many people end up in hospital unnecessarily, and are prescribed doses of medication that are also unnecessary, and potentially harmful when taken for long periods of time. We are concerned about the cost involved, both to the individuals in question and to society at large. We are also troubled by the degree of medicalisation of human experience and/or suffering, and the amount of expertise that is claimed in the treatment of severe ‘mental health problems’.
The Soteria approach is phenomenological, which means that one starts with the experience of the other, without preconceptions as to the nature, the cause, or the ‘treatment’ of their ‘condition’. Of course, because of the experience we have accrued, we have some notion of what may well be helpful. Providing a place of sanctuary, a shelter in the storm, is an age-old tradition. This is not rocket science we’re dealing with. And yet, the task is demanding. Being alongside someone in extreme states of mind and body is challenging and requires discipline and dedication. We are well aware of the need for building a strong community and a well structured and professional service, and this is what we are working to realise. Our fundamental aim is to provide a safe place/space for people to be, typically for a period of months, until such a time that they are able to return to their own home.
The Soteria Model
‘Soteria’ is a Greek word which means ‘hope‘, ‘deliverance’ and ‘salvation’. Loren Mosher, who set up the first Soteria House, chose this word because he felt that it conveyed a sense that recovery from ‘schizophrenia’ was possible (which contrasts with what most people who receive this diagnosis are generally told), and that the chances of a good recovery would be greater with the provision of a safe and supportive environment.
The original Soteria House was set up in California in the 1970s. Its aim was to establish whether people experiencing a ‘first episode’ acute psychosis, who might otherwise be diagnosed with schizophrenia and treated with medication in hospital, might fare just as well in a house with minimum medication, but with high levels of interpersonal support. The emphasis in Soteria House was on community, establishing meaningful relationships, being with rather than doing to, and perhaps most fundamentally on understanding the experience of psychosis from the point of view of the person experiencing it.
The emphasis in the Soteria model then is on providing a safe, supportive, consistent and emotionally relaxing environment, rather than engaging people in therapy, as such an environment is believed to be the crucial factor in recovery. The primary aim is to support someone through an episode of acute psychosis/extreme mental distress, with a minimum of medication, such that they are then able to return to their own homes, hopefully having found meaning in their experience in such a way that acute psychotic episodes are less likely in the future.
The original Soteria House accommodated around 6-8 persons experiencing psychosis, with at least two staff on duty at any one time. Though the staff were professionally supervised, the majority of those working in the house were non-professional staff. Rather they were chosen because of their personal qualities. This was in order to support the phenomenological approach and because of the emphasis on relationships in the approach. As is recognised in some NHS policy, it is the quality of relationships that helps to maximise safety.
The original Soteria project has inspired a number of similar projects around the world, some of which have been a part of established medical institutions (most notably in Germany), whilst others have operated independently of statutory services (whilst still being funded by the government/insurance companies). At present there are Soteria projects/houses running in Alaska, Switzerland, Germany and Hungary.
Research published on the first Soteria House in the US showed that residents had lower psychopathology scores and fewer readmissions than those treated in hospital. Only 20% took antipsychotic medication on a long-term basis, and those who didn’t take any antipsychotic medication fared best of all.
Similarly positive results were observed in research into the Soteria Berne project (which has been running for over 27 years, serving an estimated 1200 people). The Bern studies found that, on the subjective level of experience, most service users and relatives found treatment at Soteria to be less upsetting and less stigmatising than traditional methods. Soteria service users appeared to be more able to integrate their psychosis into their lives and personal development than patients being treated in customary psychiatric facilities. The authors stated that only “10-15% of randomly assigned schizophrenia patients, with whom no working alliance could be established, could not be adequately treated in the open Soteria setting.”
In 2007 a systematic review was undertaken of all controlled trials that had assessed the efficacy of the Soteria paradigm and concluded as follows:
“The studies included in this review suggest that the Soteria paradigm yields equal, and in certain specific areas better, results in the treatment of people diagnosed with first- or second-episode schizophrenia spectrum disorders (achieving this with considerably lower use of medication) when compared with conventional, medication-based approaches.”
The fact that these results were achieved with considerably lower use of medication is of course significant due to the limitations of anti-psychotic medication. The relapse rate among patients with a diagnosis of schizophrenia on medication remains high and noncompliance with treatment is frequently seen as a problem (1). In addition, some people do not respond to antipsychotic medication at all (2). Recent research continues to point to high levels of morbidity and lower life expectancy for people taking atypical antipsychotic medication on a long-term basis (3), with this risk operating via an increased incidence of fatal cardiac arrhythmias and obesity (4). Service users themselves have questioned the overreliance on medication (5). They have also complained that side effects which are not obviated by the latest atypical antipsychotics, such as loss of motivation, sexual dysfunction, weight gain, drowsiness, and restlessness, are very troubling for them (6).
Our primary aim is to establish a Soteria house in Brighton for people experiencing psychosis for the first time, a close replication of the original Soteria house, but a house/service designed for Brighton in the 2010s as opposed to California in the 1970s. We are also interested in developing services for people with ongoing experiences of psychosis, as well as more community based-services, along the lines of the Open Dialogue model from Western Lapland. We recognise that one size doesn’t fit all, but we have to start somewhere. We are actively involved in developing our service model, as well as a business plan, and considering ways of evaluating/researching the service once it is established.
We have noticed growing levels of dissatisfaction among service users, carers and professionals as to the lack of choice in service provision for people experiencing psychosis, and the singular reliance on biomedical models and treatments. A recent conference organised by the Soteria Network in the UK attracted over 300 people in Derby, for instance, including many senior clinical staff working within the NHS, and we feel like the time is right for the introduction of the Soteria model into services in the UK.
Soteria Brighton does not seek to be oppositional. In fact we have a keen interest in ways of collaborating and working with other services, statutory and otherwise. This fits well with current government agendas about the involvement of the third sector in public services, in the interest of offering greater choice to the public. So, if you are an individual or an organisation who is interested in helping us develop and implement our vision and/or forming links with us, do get in touch.
1. Department of Health. Building on the Best: Choice, Responsiveness and Equity in the NHS. London, UK: DoH; 2003.
2. Darzi A. High Quality Care for All: NHS Next Stage Review (Final Report). Department of Health London; 2008.
3. Department of Health. National Service Framework for Mental Health. London, UK: DoH; 1999.
4. Fulford KWM. Concepts of disease and the meaning of patient-centred care. In: Fulford KWM, Hope T, eds. Essential Practice in Patient-Centred Care. Oxford, UK: Blackwell Science Ltd; 1996:3–4.
5. Hope T. Evidence-based patient choice and psychiatry. Evid Based Ment Health. 2002;5:100–101.
6. Agar-Jacomb KM. Mental Health Crisis Services: What do Service Users Need When in Crisis? A Retrospective Study. Auckland, New Zealand: Department of Psychology, Uni- versity of Auckland; 2006.